Provider Demographics
NPI:1669683405
Name:FAGAN, BRYAN CHRISTOPHER (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:CHRISTOPHER
Last Name:FAGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:499 GLOSTER CREEK VLG
Mailing Address - Street 2:STE G1
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4751
Mailing Address - Country:US
Mailing Address - Phone:662-377-2663
Mailing Address - Fax:662-377-6706
Practice Address - Street 1:499 GLOSTER CREEK VLG
Practice Address - Street 2:STE G1
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4751
Practice Address - Country:US
Practice Address - Phone:662-377-2663
Practice Address - Fax:662-377-6706
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAU5009697-756207X00000X
MS20606207XX0005X, 207XX0801X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I205607OtherMEDICARE ID
MS02629297Medicaid
MS00359815Medicaid